Par-Q+ - The Physical Activity Readiness Questionnaire for Everyone

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The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physically active is very safe for MOST people. However, some should check with their doctor, another health care practitioner who is licensed to diagnose, or a qualified exercise professional before they start becoming much more physically active. This questionnaire will tell you whether it is necessary for you to seek further advice before becoming more physically active or engaging in a fitness appraisal.

GENERAL HEALTH QUESTIONS

Please read the 8 questions below carefully and answer each one honestly: check YES or NO.

date_time

id

1a) Has your doctor ever said that you have a heart condition?

No

Yes

1b) Has your doctor ever said that you have high blood pressure?

No

Yes

2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?

No

Yes

3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

No

Yes

4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

No

Yes

PLEASE LIST CONDITION(S) HERE:

5) Are you currently taking prescribed medications for a chronic medical condition?

No

Yes

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:

6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.

No

Yes

PLEASE LIST CONDITION(S) HERE:

7) Has your doctor ever said that you should only do medically supervised physical activity?

No

Yes

FOLLOW-UP QUESTIONS ABOUT YOUR MEDICAL CONDITION(S)

1. Do you have Arthritis, Osteoporosis, or Back Problems?

No

Yes

1a. Do you have difficulty controll ing your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

No

Yes

1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?

No

Yes

1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months?

No

Yes

2. Do you currently have Cancer of any kind?

No

Yes

2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?

No

Yes

2b. Are you currently receiving cancer therapy (such as chemotherapy or radiotherapy)?

No

Yes

3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm

No

Yes

3a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

No

Yes

3b. Do you have an irregular heart beat that requires medical management?

No

Yes

3c. Do you have chronic heart failure?

No

Yes

3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?

No

Yes

4. Do you have High Blood Pressure?

No

Yes

4a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

No

Yes

4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)

No

Yes

5. Do you have any Metabolic Conditions? This includes Type 7 Diabetes, Type 2 Diabetes, Pre-Diabetes

No

Yes

5a. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?

No

Yes

5b. Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headed ness, mental confusion, difficulty speaking, weakness, or sleepiness.

No

Yes

5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?

No

Yes

5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?

No

Yes

5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?

No

Yes

6. Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer's, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome

No

Yes

6a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

No

Yes

6b. Do you have Down Syndrome AND back problems affecting nerves or muscles?

No

Yes

7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure

No

Yes

7a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

No

Yes

7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?

No

Yes

7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?

No

Yes

7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?

No

Yes

8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia

No

Yes

8a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

If you are over the age of 45 years and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a qualified exercise professional.

You have answered YES to one or more of the general questions and YES to one or more of the follow-up questions about your medical condition. You should seek further information from a qualified exercise professional before becoming more physically active or engaging in a fitness appraisal.

Delay becoming more active if:

You have a temporary illness such as a cold or fever; it is best to wait until you feel better.

Your health changes - talk to your doctor or qualified exercise professional before continuing with any physical activity program.

I have read, understood to my full satisfaction and completed the questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that a Trustee (such as my employer, community/fitness centre, health care provider, or other designate) may retain a copy of this form for their records. In these instances, the Trustee will be required to adhere to local, national, and international guidelines regarding the storage of personal health information ensuring that the Trustee maintains the privacy of the information and does not misuse or wrongfully disclose such information.

Name

I understand that checking this box consitutes a legal signature confirming that I acknowledge and agree to the above.